Not a perfect fit

By M.L. Baker |
Posted 03-23-2005

Duke Health Uses IT to Get Beyond Doctors' Handwriting

Duke University Health System recently implemented a CPOE system to cover patients in 350 beds. It improves workflow, but it also helps Duke avoid errors based on bad handwriting or misplaced bits of paper.

Fewer than 5 percent of hospitals have deployed computerized physician order entry systems, but they are a hot topic, and not only for their technical merits.

Analysts expect CPOE to reduce medication errors, remind doctors of the most current treatment guidelines, and keep doctors from ordering unnecessary tests or off-formulary drugs.

Physicians have frequently refused to use systems that require too much time or hassle.

Hospital executives are becoming increasingly aware that CPOEs must be designed to complement the workflow of the hospital in which they are deployed.

Hospitals should not expect to buy a usable product off the shelf, however. Like medical treatment plans, each has to be customized to the individual patient.

"CPOE is one system that no hospital can just deploy. What you buy from a vendor is just a shell," said Asif Ahmad, VP and CIO of Duke University Health System.

"It's like a notebook that you have to write everything in. That's where the struggle comes in."

Duke has formed a research collaboration with McKesson Corporation, with the idea that other hospital executives can use Duke's experience implementing a CPOE system to ease deployment of CPOEs at their own institutions.

Good workflows and speedy deployment are the characteristics Ahmad sees as key to implementing a CPOE system.

"Don't make IT a never-ending story," he said. "If you do partial implementation, you make the system more complicated and harder to handle."

If some functions are handled on paper while others are managed online, nurses and pharmacists will have to duplicate work as the project drags on, and excitement about the project will flag.

But though implementation should go as quickly as possibly, no one should cut corners in the planning stages, in which hospital workers figure out what each department needs to CPOE system to do.

"Don't just figure out one ICU [intensive care unit] methodology for everybody, because it doesn't work that way," said Ahmad. "One of the easiest mistakes to make is not to take time to map our workflow; a lot of people start deploying units without understanding the culture."

"[Mapping workflows] is a tedious process and requires the ability to translate physician-speak into computerese," said assistant CIO Michael Russell.

For each discipline, "you make rounds repetitively with those responsible. Sit and read through somewhere between 500 and 1000 orders, perhaps a week's worth from a unit, so we grasp what they are doing day in and day out."

And then there are committee meetings to make sure the tasks of each member of a hospital team are incorporated.

In fact, Ahmad warned that the workflow process often pays too much attention to physicians, who order medicine from the system, and not enough attention on nurses, whose workflow can be more drastically changed by the system.

In addition, said Russell, many of the experts on the programming side had worked as clinicians and understood the chaotic nature of hospitals.

Not a perfect fit

Even once implemented, the CPOE will not be a perfect fit.

"In a paper world, so many processes are malleable in ways that they are no longer malleable [with CPOE]," according to James Tcheng, associate professor of medical health systems, who worked on the project.

He described one example. When heart doctors realize a patient receiving a cardiac catheter needs to be admitted to the hospital for cardiac care, the paper system would let doctors write orders before the patient is formally admitted, a process that was not allowed with the CPOE system and caused delays.

Tcheng recalled that it was not immediately clear what was causing the delays. "It took a bit of detective work."

However, once the problem was identified, a new unit was added to the CPOE system, allowing that cardiology unit to admit patients virtually.

Tcheng said that the technical solution was much easier than the political one of explaining to the admitting and billing offices why the cardiac unit needed to be able to "admit" patients on its own.

Administrators needed to be convinced that doctors wouldn't be violating regulations with a virtual admission process.

After examining the workflow in each department, the Duke team laboriously identified sets of activities that come together, with the idea of automating processes as much as possible.

"When a patient is admitted with chest pains, there's only certain ways to treat the patient, certain drugs, certain procedures," Ahmad said. "If you select cardiac admission [on the CPOE system], one click puts all those tasks on the side. The system will prompt you with all the things that are set up to happen."

The team first organized the order sets into a superstructure called the ontology, Tcheng said.

"We put together the ontology and populated it with order sets like categories of admissions, disease management, rounding."

Ultimately, each department needed to be represented by similar architecture. "We had to make it look fairly uniform across the hospital, when you open the CPOE you can get where you want to go promptly and understand how order sets were organized."

The result, said Ahmad, is a lot less "zigzagging" both in physical terms and in terms of communications between doctors and nurses, and an enthusiastically accepted system.

"Previously, the physician would round in morning and go from bed to bed and then go back to order book, go back to next room, and then go to computer in between to look at lab results. Now we have laptops on gurneys the physician can take from bed to bed and see everything they need at once."

In addition, orders sent to labs and pharmacists are clearer than orders scribbled on paper, said Ahmad, so doctors "get rid of nuisance calls from lab and pharmacy asking 'what did you really want?'"

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